Provider Demographics
NPI:1063411262
Name:PROVIDENCE REST
Entity type:Organization
Organization Name:PROVIDENCE REST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:718-931-3000
Mailing Address - Street 1:3304 WATERBURY AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-1554
Mailing Address - Country:US
Mailing Address - Phone:718-931-3000
Mailing Address - Fax:718-514-8447
Practice Address - Street 1:3304 WATERBURY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-1554
Practice Address - Country:US
Practice Address - Phone:718-931-3000
Practice Address - Fax:718-514-8447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7000306N385H00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1216OtherFACILITY
NY007381OtherBLUE CROSS/ BLUE SHIELD
NY00309357Medicaid
NY01133297Medicaid
NY01133297Medicaid